Provider Demographics
NPI:1417933912
Name:NICHOLSON, CRAIG ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ANTHONY
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 PARK PLACE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1303
Mailing Address - Country:US
Mailing Address - Phone:817-924-9292
Mailing Address - Fax:
Practice Address - Street 1:1601 PARK PLACE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1303
Practice Address - Country:US
Practice Address - Phone:817-924-9292
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist